Pneumonia in a child

Pneumonia in a child is an acute infectious disease of a predominantly bacterial nature, characterized by focal damage to the respiratory parts of the lungs, respiratory disorders and intra-alveolar exudation, as well as infiltrative changes in light radiographs. The presence of radiological signs of the infiltration of the pulmonary parenchyma - the “gold standard” of the diagnosis of pneumonia, which allows it to distinguish it from bronchitis and bronchiolite.

MKB-10 code

• J12 Viral pneumonia, not classified in other headings.
• J13 pneumonia caused by Streptococcus pneumoniae.
• J14 pneumonia caused by haemophilus influenzae (Afanasyev-Pfeiffer stick).
• J15 bacterial pneumonia, not classified in other headings.
• J16 pneumonia caused by other infectious pathogens, not classified in other headings.
• J17 pneumonia in diseases classified in other headings.
• J18 pneumonia without specifying the pathogen.

Epidemiology of pneumonia in children

Pneumonia is diagnosed in approximately 15-20 cases for 1000 children of the first year of life, in approximately 36-40 cases per 1000 children at preschool age, and in school and adolescence the diagnosis of “pneumonia” is set in approximately 7-10 cases per 1000 children and adolescents.

The frequency of hospital pneumonia depends on the contingent and the age of patients (amounts to up to 27% of cases of all nosocomial infections), it is maximum in young children, especially in newborns and premature babies, as well as in children who have undergone surgery, injury, burns, etc.

Mortality from pneumonia (along with influenza) on average is 13.1 per 100,000 population. Moreover, the highest mortality is observed in the first 4 years of life (it reaches 30.4 per 100,000 population), the smallest (0.8 per 100,000 population) is observed at the age of 10-14 years.

Mortality from hospital pneumonia, according to the national monitoring system of nosocomial infections of the United States, was 33-37%at the turn of the past and current centuries. In the Russian Federation, the mortality of children from hospital pneumonia during this period has not been studied.

[1], [2], [3], [4]

Causes of pneumonia in children

The most frequent pathogens of community-acquired pneumonia are Streptococcus pneumoniae (20-60%), Mycoplasma pneumoniae (5-50%), Chlamydia pneumoniae (5-15%), Chlamydia trachomatis (3-10%),,,,

Haemophilus influenzae (3-10%), Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli, etc.-3-10%), Staphylococcus aureus (3-10%), Streptococcus Pyogenes, Chlamydia Psittaci, Coxiella Bumeti and others. However, it must be borne in mind that the etiology of pneumonia in children and sneakers is very closely related to age.

In the first 6 months of the child’s life, the etiological role of pneumococcus and hemophilic sticks is insignificant, since antibodies are transmitted from the mother to these pathogens. The leading role at this age is played by E. coli, K. pneumoniae and S. aureus. The etiological significance of each of them does not exceed 10-15%, but it is they who determine the most severe forms of the disease, complicated by the development of infectious toxic shock and the destruction of the lungs. Another group of pneumonics of this age - pneumonia caused by atypical pathogens, mainly C. trachomatis, which children become infected from the mother intranatally, rarely - in the early days of life. It is also possible to infect R. Carinii, which is especially significant for premature children.

From 6 months to 6-7 years of pneumonia, it mainly causes S. pneumoniae (60%). Often, a free-capsule hemophilic stick is also sown. H. Influenzae type B is detected less often (7-10%), it determines, as a rule, heavy pneumonia, complicated by the destruction of the lungs and pleurisy.

Pneumonia caused by S. aureus and S. pyogenis is detected in 2-3% of cases usually as complications of severe viral infections, such as flu, chickenpox, measles and herpes. Pneumonia caused by atypical pathogens in children of this age are mainly due to M. Pneumoniae and C. pneumoniae. I must say that the role of M. pneumoniae has clearly increased in recent years. Mycoplasma infection is mainly diagnosed in the second or third year of life, and C. pneumoniae infection is in children over 5 years old.

Viruses in children of this age group can be both an independent cause of the disease or a participant in viral-bacterial associations. The most important is the respiratory-synthetic (PC) virus, which occurs in approximately half of cases of viral and virus-bacterial nature. In a quarter of cases, the viruses of the paragerippus types 1 and 3 become the etiological factor. The influenza A and B viruses and adenoviruses play a small role. Rhinoviruses, enteroviruses, coronaviruses are rarely detected. Pneumonia caused by measles, rubella and chickenpox are also described. As already mentioned, in addition to independent etiological significance, a respiratory viral infection in children of early and preschool age is an almost mandatory background for the development of bacterial inflammation.

The causes of pneumonia in children over 7 years old and adolescents are practically no different from that in adults. The most common pneumonia is caused by S. pneumoniae (35-40%) and M. pneumoniae (23-44%), less often-S. pneumoniae (10-17%). N. Influenzae type b, and such pathogens as Enterobacteriaceae (K. Pneumoniae, E. Coli, etc.) and S. aureus are practically not found.

It is especially worth mentioning pneumonia in patients with immunodeficiency. In children with primary cellular immunodeficiencies, in HIV-infected patients and AIDS patients, pneumonia is more often caused by Pneumocysticus Carinii and mushrooms of the genus Candida, as well as M. Avium-intracellare and cytomegalovirus. With humoral immunodeficiency, S. pneumoniae is more often sown, as well as staphylococci and enterobacteria, with neutropenia, gram-negative enterobacteria and mushrooms.

Causes of community-acquired pneumonia in patients with immunodeficiency

Groups of patients	Pathogens
Patients with primary cellular immunodeficiency	Pneumocysts of the genus of the genus Candida
Patients with primary humoral immunodeficiency	Pneumococci Staphylococci Enterobacteria
Patients with acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocysts Cytomegaloviruses of mycobacteria of tuberculosis Mushrooms of the genus Candida
Patients with neutropenia	Gram-negative enterobacteria Mushrooms of the genus Candida, Aspergillus, Fusarium

[5], [6], [7], [8], [9] 10

Pathogenesis of pneumonia in children

Of the characteristics of pneumonia pathogenesis in young children, the low level of anti-infectious protection is most important. In addition, we can note the relative deficiency of mucociliary clearance, especially with a respiratory viral infection, with which, as a rule, pneumonia in the child begins. The tendency to edema of the mucous membrane of the respiratory tract and the formation of viscous sputum also contributes to a violation of mucociliary clearance.

Four main reasons for the development of pneumonia are known:

• Aspiration of the secret of the oropharynx;
• Inhalation of aerosol containing microorganisms;
• The hematogenous spread of microorganisms from the gangster focus of infection;
• The direct spread of infection from neighboring affected organs.

In children, the microaspiration of the tensity of the oropharynx is of the greatest importance. Aspiration of a large number of contents of the upper respiratory tract and/or stomach is characteristic of newborns and children of the first months of life. Less commonly, aspiration occurs during feeding and/or in vomiting and regurgitation. In children of early and preschool age, the most significant obstruction of the respiratory tract, especially in the case of bronchial-structural syndrome.

Factors predisposing to aspiration/microaspiration

• Encephalopathy of various genesis (post-hypic, with malformations of the brain and hereditary diseases, convulsive syndrome).
• Dysphagia (vomiting syndrome, esophagus-tracheal fistulas, cardia ahalaia, gastroesophageal reflux).
• Bronchial-constructive syndrome for respiratory, including viral, infection.
• Mechanical disorders of protective barriers (nasogastric probe, trachea intubation, tracheostomy, esophagogastroduodenoscopy).
• Repeated vomiting with intestinal paresis, severe infectious and somatic diseases.

What causes pneumonia?

Symptoms of pneumonia in children

The classic symptoms of pneumonia in children are non-specific - this is shortness of breath, cough (with sputum and without it), fever, weakness, symptoms of intoxication. The development of pneumonia should be assumed if the child has a cough and/or shortness of breath, especially in combination with an increase in body temperature. The corresponding percussion and auscultative changes in the lungs, namely, shortening of the percussion sound, weakening or, conversely, the appearance of bronchial respiration, crepitus, or small-buttoned rales are determined only in 50-77% of cases. It should be remembered that in early childhood, especially in children of the first months of life, these manifestations are typical for almost any acute respiratory infection, and physical changes in the lungs with pneumonia in most cases (with the exception of lobar pneumonia) are practically indistinguishable from changes in bronchitis.

Symptoms of hospital (nosocomial) pneumonia in children

According to WHO, for the symptoms of pneumonia in children are characterized by the following features:

• Feverish condition with body temperature above 38 ° C for 3 days or more;
• Shortness of breath (with a number of respiratory movements of more than 60 per minute for children up to 3 months, more than 50 per minute - up to 1 year, more than 40 per minute - up to 5 years);
• Continuration of compliant places of the chest.

Classification

It is customary to divide pneumonia in children, depending on the conditions of their occurrence into extra-acquired (home) and hospital (hospital, nosocomial). The exception is pneumonia of newborns, which are divided into congenital and acquired (postnatal). Postnatal pneumonia, in turn, can also be community and hospital.

By community pneumonia (VP) is understood as a disease that developed under the usual conditions of the life of a child. Under hospital pneumonia (GP) - a disease that developed after a three-day stay of a child in a hospital or during the first 3 days after his discharge.

It is customary to consider the fan-component hospital pneumonia (WAGP) and fan-absorpted hospital pneumonia (NALP). Early, developing in the first 3 days of artificial ventilation of the lungs (IVL), and late, developing from 4 days of Ivl, are distinguished.

Pneumonia can affect the whole share of the lung (shared pneumonia), one or more segments (segmental or polysegmental pneumonia), alveoli or alveoral group (focal pneumonia), adjacent to bronchi (bronchopneumonia), or affect interstitial tissue (interstitial pneumonia). These differences are detected mainly during physicist and radiological examination.

According to the severity of the current, the degree of damage to the pulmonary parenchyma, the presence of intoxication and complications distinguish light and heavy, uncomplicated and complicated pneumonia.

The complications of pneumonia include an infectious-toxic shock with the development of multiple organ failure, the destruction of the pulmonary parenchyma (bulls, abscesses), the involvement of pleura in the infectious process with the development of pleurisy, empyem or pneumothorax, mediastinitis, etc.

Types of pneumonia

[11], [12], [13]

Complications of pneumonia in children

[14], [15], [16], [17]

Intra-lane destruction

Into-lane destruction is a suppuration with the formation of bull or abscesses at the site of cell infiltration in the lungs caused by some pneumococcus serotypes, staphylococci, H. influenzae type B, hemolytic streptococcus, Klebsiella, and prayed rod. Elongation suppurations are accompanied by fever and neutrophilic leukocytosis until the emptying, which occurs either in the bronchus, accompanied by an increase in cough or into the pleural cavity, causing pyopneumothorax.

Synpneumonic pleurisy

Synpneumonic pleurisy can cause any bacteria and viruses, starting with pneumococcus and completing mycoplasma and adenovirus. Purulent exudate is characterized by low pH (7.0-7.3), cytosis above 5,000 leukocytes in 1 μl. In addition, exudate can be fibrinous-native or hemorrhagic. With adequate antibacterial therapy, exudate loses its purulent character and pleurisy is gradually resolved. However, a complete recovery occurs after 3-4 weeks.

Metapneumonic pleurisy

Metapneumonic pleurisy usually develops in the stage of resolution of pneumococcal, less often - hemophilic pneumonia. The main role in its development belongs to immunological processes, in particular, the formation of immune complexes in the pleura cavity against the background of the decay of microbial cells.

As already mentioned, the metapneumonic pleurisy develops at the stage of resolution of pneumonia after 1-2 days of normal or subnormal temperature. The body temperature again rises to 39.5-40.0 ° C, a violation of the general state is expressed. The feverish period lasts an average of 7 days, and antibacterial therapy does not affect it. Radiologically detect pleurisy with fibrin flakes, in some children with echocardiography, pericate is detected. In the analysis of peripheral blood, the number of leukocytes is normal or reduced, and ESR is increased to 50-60 mm/h. The resorption of fibrin occurs slowly, within 6-8 weeks, due to the low fibrinolytic activity of the blood.

Piopneumotorax

Piopneumothorax develops as a result of a breakthrough of the abscess or bulls into the pleura cavity. There is an increase in the amount of air in the pleural cavity and, as a result, the displacement of the mediastinum.

Piopneumothorax usually develops unexpectedly: pain syndrome, respiratory disorders up to respiratory failure acutely occur. With tense valve piopneumothorax, urgent decompression is indicated.

Symptoms of pneumonia

Diagnosis of pneumonia in children

During the physicive examination, special attention is paid to the identification of the following signs:

• Shortening (dullness) of percussion sound above the affected area of the lung;
• Local bronchial respiration, sonorous fine-bubble wheezing or inspiratory crepitus during auscultation;
• Strengthening bronchophony and vocal trembling in older children.

In most cases, the severity of these symptoms depends on many factors, including the severity of the disease, the prevalence of the process, the age of the child, the presence of concomitant diseases. It must be remembered that physical symptoms and coughing can be absent in approximately 15-20% of patients.

Analysis of peripheral blood must be carried out by all patients with suspicion of pneumonia. The number of leukocytes is about 10-12x10 ⁹/l indicates a high probability of bacterial infection. Leukopenia is less than ZX10 ⁹/l or leukocytosis more than 25x 10 ⁹/l-adverse prognostic signs.

The radiography of the chest organs is the main method of diagnosis of pneumonia. The main diagnostic feature is inflammatory infiltrate. In addition, the following criteria are evaluated, which indicate the severity of the disease and help in the choice of antibacterial therapy:

• Lung infiltration and its prevalence;
• The presence or absence of pleural effusion;
• The presence or absence of destruction of the pulmonary parenchyma.

Repeated radiography allows you to evaluate the dynamics of the process against the background of treatment and the completeness of recovery.

Thus, the clinical and radiological criteria for the diagnosis of extra-acquired pneumonia consider the presence of changes in light infiltrative nature detected by radiography of the chest organs, in combination with at least two of the following clinical signs:

• Acute feverish on the disease (T & GT; 38.0 ° C);
• Cough;
• Auscultative signs of pneumonia;
• Leukocytosis & gt; 10x10 ⁹/l and/or rod-core shift & gt; 10%. It is important to remember that the clinical-radiological diagnosis cannot be equated with an etiological diagnosis!

Biochemical blood test is a standard method for examining children with severe pneumonias who need hospitalization. The activity of liver enzymes, the level of creatinine and urea, electrolytes in the blood are determined. In addition, the acid-base state of the blood is determined. In young children, pulsoximetry is carried out.

Blood sowing is performed only with severe pneumonia and, if possible, before the use of antibiotics in order to make an etiological diagnosis.

Microbiological examination of sputum in pediatrics is not widely used in connection with the technical difficulties of sputum collection in children under 7-10 years old. It is carried out mainly with bronchoscopy. As a material for the study, crooked sputum, aspirates from the nasopharynx, tracheostoma and endotracheal tube, and crops of pleural contents are taken.

Serological research methods are also used to clarify the etiology of the disease. The growth of titers of specific antibodies in paired serums taken in the acute period and during recovery may indicate mycoplasmic, chlamydial or legionella infection. This method, however, does not affect the tactics of treatment and has only epidemiological significance.

Computed tomography has 2 times higher sensitivity when identifying foci of infiltration in the lower and upper lobes of the lungs. Use it when conducting differential diagnosis.

Fibrobronchoscopy and other invasive techniques are used to obtain material for microbiological research in patients with severe immunity disorders during differential diagnosis.

[18], [19], [20]

Differential diagnosis

The differential diagnosis of pneumonia in children is closely related to the age of the child, since it is determined by the features of the pulmonary pathology in various age periods.

At infants, the need for differential diagnosis occurs for diseases that are difficult to treat. In these cases, it should be remembered that, firstly, pneumonia can complicate another pathology, and secondly, clinical manifestations of respiratory failure can be due to other conditions:

• Aspiraza;
• A foreign body in the bronchi;
• Not previously diagnosed with tracheoesophageal fistula, gastroesophageal reflux;
• Malformations of the lung (shared emphysema, koloboma), heart and large vessels;
• Cystic fibrosis and angantyripsin deficiency.

In children 2-3 years of life and at an older age, it should be excluded:

• Cartagener syndrome;
• Lung hemosiderosis;
• Nonspecific alveolitis;
• Selective immunodeficiency IGA.

Diagnostic search in patients of this age is based on an endoscopic examination of the trachea and bronchi, conducting scintigraphy and lung angiography, cystic fibrosis trials, determining the concentration of agagansin, etc. Finally, in all age groups, it is necessary to exclude lung tuberculosis.

In patients with severe defects in immunity, when shortness of breath and focal-infiltrative changes in the lungs appear, it is necessary to exclude:

• Progression of the underlying disease;
• Involvement of lungs in the main pathological process (for example, with systemic diseases of connective tissue);
• The consequences of the therapy (drug damage to the lungs, radiation pneumonitis).

Diagnosis of pneumonia

[21], [22], [23], [24], [25], 26 [27]

Treatment of pneumonia in children

Treatment of pneumonia in children begins with determining the place where they will be carried out (with community-acquired pneumonia) and the immediate prescription of antibacterial therapy to any patient with suspected pneumonia.

Indications for hospitalization in pneumonia in children are the severity of the disease, as well as the presence of risk factors for the adverse course of the disease (modifying risk factors). These include:

• The age of the child is less than 2 months regardless of the severity and prevalence of the process;
• The age of the child is up to 3 years with the lobar nature of the lung lesions;
• Defeat of two or more lungs (regardless of age);
• Children with severe encephalopathy of any genesis;
• Children of the first year of life with intrauterine infection;
• Children with hypotrophy of the II-III degree of any genesis;
• Children with congenital malformations, especially with congenital heart defects and large vessels;
• Children suffering from chronic diseases of the lungs (including bronchopulmonary dysplasia and bronchial asthma), cardiovascular system, kidneys, as well as oncgetological diseases;
• Patients with immunodeficiency (for a long time taking glucocorticoids, cytostatics);
• The impossibility of adequate care and the implementation of all medical prescriptions at home (socially dysfunctional families, poor socio-living conditions, religious views of parents, etc.);

Indication for hospitalization in the intensive care and intensive care unit (ORI) or in the intensive care unit (OIT), regardless of modifying risk factors, is a suspicion of pneumonia in the presence of the following symptoms:

• Respiratory movements of more than 80 per minute for children of the first year of life and more than 60 per minute for children over one year old;
• Drawings of a yemic fossa during breathing;
• Groaning breathing, respiratory rhythm disturbances (apnea, gaspsy);
• Signs of acute cardiovascular failure;
• Unconscious or progressive hypothermia;
• Violations of consciousness, seizures.

Indication for hospitalization in the surgical department or in ith/ot with the possibility of adequate surgical care - the development of pulmonary complications (synpneumonic pleurisy, metapneumonic pleurisy, pleural empyem, destruction of the lungs, etc.).

Antibacterial treatment of pneumonia in a child

The main method of treatment of pneumonia in children is antibacterial therapy, which is prescribed empirically until the results of the bacteriological examination are obtained. As you know, the results of a bacteriological study become known after 2-3 days or more after the fence of the material. In addition, in the vast majority of cases of the mild course of the disease, children do not hospitalize and do not conduct a bacteriological study. That is why it is so important to know about the likely etiology of pneumonia in various age groups.

Indications for the replacement of antibiotics/antibiotics are the lack of a clinical effect within 36-72 hours, as well as the development of side effects.

Criteria for the absence of the effect of antibacterial therapy:

• Preservation of body temperature more than 38 ° C;
• Deterioration of general condition;
• An increase in changes in the lungs or in the pleural cavity;
• Growing shortness of breath and hypoxemia.

In case of adverse prognosis, treatment is carried out according to the de-escalation principle, i.e. They begin with antibacterial drugs with the most wide range of action, followed by the transition to drugs of a narrower spectrum.

Features of the etiology of pneumonia of children in the first 6 months of life make the drugs even in case of low pneumonia inhibitor-lowered amoxicillin (amoxicillin + clavulanic acid) or cephalosporin II generation (cofuroxim or cephasolin), with severe pneumonia - cephalosporins of the III generation (cefrixon, cefotaxim) in monotherapy either in combination with aminoglycosides, or in a combination of amoxiclav + clavulanic acid with aminoglycosides.

The child has up to 6 months with a normal or subfebrile temperature, especially in the presence of obstructive syndrome and indications of vaginal chlamydia in the mother, you can think about pneumonia due to C. trachomatis. In these cases, it is advisable to immediately prescribe a macroline antibiotic (azithromycin, roxytomycin or spiramycin) inside.

In premature babies, it should be remembered about the possibility of pneumonia caused by R. Carinii. In this case, along with antibiotics, co-trimoxazole is prescribed. When confirming pneumocystal etiology, they switch to monoterpion with co-troxazole lasting at least 3 weeks.

In pneumonia, burdened by the presence of modifying factors or with a high risk of adverse outcome, the drugs of choice are an inhibitor-protective amoxicillin in a combination with aminoglycosides or cephalosporins of the III or IV generation (ceftriaxone, cefotaxim, cepherapy) in monotherapy or in combination with aminoglycosides depending on the severity of the disease, carbapenems (imipena + cylastatin from the first month of life, meropen from the second month of life). With staphylococcal etiology, linemicin or vancrikomin is prescribed separately or in combination with aminoglycosides, depending on the severity of the disease.

Alternative drugs, especially in cases of development of destructive processes in the lungs, are linenesolide, vancrikomicin, carbapenema.

The choice of antibacterial drugs in children of the first 6 months of life with pneumonia

Form of pneumonia	Preparations of choice	Alternative Therapy
Small typical pneumonia	Amoxicillin + clavulanic acid or cephalosporins of the II generation	Cephalosporins of the II and III generation in monotherapy
Heavy typical pneumonia	Amoxicillin + clavulanic acid + aminoglycoside or cephalosporins of the III or IV generation in monotherapy or in combination with aminoglycosides. Linezolide or vanc-committee in monotherapy or in combination with aminoglycosides	Carbapenems
Atypical pneumonia	Macro-cast antibiotic	-
Atypical pneumonia in a premature child	Co-trimoxazole

At the age of 6-7 to 6-7 years, when choosing starting antibacterial therapy, three groups of patients are distinguished:

• Patients with mild pneumonia who do not have modifying factors or have modifying social plan factors;
• Patients with severe pneumonia and patients with modifying factors weighting the prognosis of the disease;
• Patients with severe pneumonia and high risk of adverse outcome.

It is most advisable for patients of the first group to prescribe antibacterial drugs inside (amoxicillin, amoxicillin + clavulanic acid or cephalosporin II generation of cofuroxim). But in some cases (lack of confidence in the implementation of the appointments, a sufficiently difficult condition of the child, if parents refuse to hospitalize, etc.), the stepped method of treatment is justified: in the first 2-3 days, antibiotics are administered parenterally, and then, with improvement or stabilization of the condition, the same drug is prescribed inside. To do this, use amoxicillin + clavulanic acid, but it must be administered intravenously, which is difficult at home. Therefore, cefuroxim is often prescribed.

In addition to ß-lactam, treatment can be carried out by macrolides. But, given the etiological significance of the hemophilic stick (up to 7-10%) in children of this age group, only azithromycin is considered the drug of choice for starting empirical therapy, to which H. Influenzae is sensitive. Other macrolides are an alternative with intolerance to ß-lactam antibiotics or with their ineffectiveness, for example, with pneumonia caused by the atypical pathogens of M. Pneumoniae and S. Pneumoniae, which is quite rare at this age. In addition, with the ineffectiveness of drugs of choice, III cephalosporins are used.

Patients of the second group showed parenteral administration of antibiotics or the use of a step method. The drugs of choice, depending on the severity and prevalence of the process, the nature of the modifying factor, are amoxicillin + clavulanic acid, ceftreakson, cefotaxim and cefuroxim. Alternative drugs with the ineffectiveness of starting therapy - cephalosporins of the III or IV generation, carbapenema. Macrolides in this group are rarely used, since the overwhelming number of pneumonia caused by atypical pathogens flows non-fragile.

Patients with a high risk of adverse outcome or with severe purulent-destructive complications are prescribed antibacterial drugs according to the de-escalation principle, which involves the use of linerosolide at the beginning of treatment separately or in combination with aminoglycoside, as well as a combination of glycopeptide or cephalosporin generation with aminoglycosides. An alternative is the purpose of carbapenems.

The choice of antibacterial drugs for the treatment of pneumonia in children from 6-7 months to 6-7 years

Form of pneumonia	The drug of choice	Alternative Therapy
Light pneumonia	Amoxicillin. Amoxicillin + clavulanic acid. Cofuroxim. Azithromycin	Cephalosporins of the II generation. Macrolides
Heavy pneumonia and pneumonia in the presence of modifying factors	Amoxicillin+ clavulanic acid. Cefuroxim or ceftriaxone. Cephotaxim	Cephalosporins of the III or IV generation separately or in combination with aminoglycoside. Carbapenems
Heavy pneumonia with a high risk of unfavorable outcome	Linezolide separately or in combination with aminoglycoside. Vancromicin separately or in combination with aminoglycoside. Cephepup is separately or in combination with aminoglycoside	Carbapenems

When choosing antibacterial drugs for pneumonia in children over 6-7 years old and adolescents, two groups of patients are distinguished:

• With mild pneumonia;
• With severe pneumonia, requiring hospitalization, or with pneumonia in a child or a teenager with modifying factors.

Antibiotics of choice for the first group - amoxicillin and amoxicillin + clavulanic acid or macrolides. Alternative drugs - cofuroxim or doxycycline, as well as macrolides, if amoxicillin or amoxicillin + clavulanic acid was prescribed before.

Antibiotics of choice for the second group - amoxicillin + clavulanic acid or cephalosporins of the II generation. Alternative drugs - cephalosporins of the III or IV generation. Macrolides should be preferred with intolerance to ß-lactam antibiotics and with pneumonia, presumably caused by M. Pneumoniae and S. Pneumoniae.

The choice of antibacterial drugs for the treatment of pneumonia in children and adolescents (7-18 years old)

Form of pneumonia	The drug of choice	Alternative Therapy
Light pneumonia	Amoxicillin, amoxicillin 4-clavulanic acid. Macrolides	Macrolides. Cofuroxim. Doxacycline
Severe pneumonia, pneumonia in children and adolescents having modifying factors	Amoxicillin 4-clavulanic acid. Cephalosporins of the II generation	Cephalosporins of the III or IV generation

In pneumonia in patients with immunity disorders, empirical therapy begins with cephalosporins of the III or IV generation, vanc-breeding or linosolide in combination with aminoglycosides. Then, as the pathogen clarifies, or the therapy continues, for example, if pneumonia is caused by Enterobacteriaceae (K. Pneumoniae, E. Coli, etc.), S. aureus or Streptococcus pneumoniae, or a co-troxazole (20 mg/kg according to trimetrome) The detection of pneumocystosis, or is prescribed fluconazole for candidiasis and amphotericin in with other mycosis. If pneumonia is caused by viral agents, then antiviral drugs are prescribed.

The duration of the course of antibiotics depends on their effectiveness, severity of the process, complication of pneumonia and the premorbid background. The usual duration is 2-3 days after obtaining a persistent effect, i.e. About 6-10 days. Complicated and severe pneumonia usually require an antibiotic therapy course of at least 2-3 weeks. In patients with immunity disorders, the course of antibacterial drugs is at least 3 weeks, but can be longer.

The choice of antibacterial drugs for pneumonia in patients with immunity disorders

Character Immunodeficiency	Etiology of pneumonia	Preparations for therapy
Primary cellular immunodeficiency	Pneumocysta Carinii. Mushrooms of the genus Candida	Co-trimoxazole 20 mg/kg in trimetrome. Fluconazole 10-12 mg/kg or amphotericin B in increasing doses, starting from 150 units/kg to 500 or 1000 units/kg
Primary humoral immunodeficiency	Enterobacteria (K. Pneumoniae E. Coli and others). Staphylococci (S. aureus, S. Epidermidis, etc.). Pneumococci	Cephalosporins of the 111 or IV generation in monotherapy or in combination with aminoglycosides. Linezolide or vanc-committee in monotherapy or in combination with aminoglycosides. Amoxicillin + clavulanic acid in monotherapy or in combination with aminoglycosides
Acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocysts. Cytomegaloviruses. Herpesvirus. Mushrooms of the genus Candida	Co-trimoxazole 20 mg/kg in trimetrome. Ganciclovir. Acyclovir. Fluconazole 10-12 mg/kg or amphotericin in increasing doses, starting from 150 units/kg to 500 or 1000 units
Neutropenia	Gramnegative Enterobacteria. Mushrooms of the genus Candida, aspergillus, fusarium	Cephalosporins of the III or IV generation in monotherapy or in combination with aminoglycosides. Amphotericin in increasing doses, starting from 150 units/kg to 500 or 1000 units

Doses, paths and the frequency of the administration of antibacterial drugs in community-acquired pneumonia in children and adolescents

Preparation	Doses	The path Introduction	Frendering Introduction
Penicillin and its derivatives
[Amoxicillin	25-50 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 8 hours	Inside	3 times a day
Amoxicillin + clavulanic acid	20-40 mg/kg body weight (according to amoxicillin). For children over 12 years old with mild pneumonia of 0.625 g every 8 hours or 1 g every 12 hours	Inside	2-3 times a day
Amoxicillin + clavulanic acid	30 mg/kg body weight (according to amoxicillin). For children over 12 years old, 1.2 g every 8 or 6 hours	In/c	2-3 times a day
Cephalosporins I and II generation
Cephasolin	60 mg/kg body weight. For children over 12 years old, 1-2 g every 8 hours	In/m, in/c	3 times a day
Cofuroxim	50-100 mg/kg body weight. For children over 12 years old, 0.75-1.5 g every 8 hours	In/m, in/c	3 times a day
Cofuroxim	20-30 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours	Inside	2 times a day
Cephalosporins of the III generation
Cephotaxim	50-100 mg/kg body weight. For children over 12 years old, 2 g every 8 hours	In/m, in/c	3 times a day
Ceftriaxone	50-75 mg/kg body weight. For children over 12 years old, 1-2 g 1 time per day	In/m, in/c	Once a day
Cephalosporins of the IV generation
Cephepup	100-150 mg/kg body weight. For children over 12 years old, 1-2 g every 12 hours	In/c	3 times a day

Carbapenems
Imipen	30-60 mg/kg body weight. For children over 12 years old, 0.5 g every 6 hours	In/m, in/c	4 times a day
Meropenem	30-60 mg/kg body weight. For children over 12 years old, 1 g every 8 hours	In/m, in/c	3 times a day
Glycopeptides
Vancomitsin	40 mg/kg body weight. For children over 12 years old, 1 g every 12 hours	In/m, in/c	3-4 times a day
Oksasolidinones
Linezolide	10 mg/kg body weight	In/m, in/c	3 times a day
Aminoglycosides
Gentamycin	5 mg/kg body weight	In/m, in/c	2 times a day
Amikacin	15-30 mg/kg body weight	In/m, in/c	2 times a day
Nonlmitmitsin	5 mg/kg body weight	In/m, in/c	2 times a day
Macrolides
Erythromycin	40-50 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 6 hours	Inside	4 times a day
Spiramycin	15,000 IU/kg body weight. For children over 12 years old, 500,000 am every 12 hours	Inside	2 times a day
Roxytromycin	5-8 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours	Inside	2 times a day
Azithromycin	10 mg/kg of body weight on the first day, then 5 mg/kg body weight per day for 3-5 days. For children over 12 years old, 0.5 g 1 time per day every day	Inside	Once a day

Tetracyclines
Doxycycline	5 mg/kg body weight. For children over 12 years old, 0.5-1 g every 8-12 hours	Inside	2 times a day
Doxycycline	2.5 mg/kg body weight. For children over 12 years old, 0.25-0.5 g every 12 hours	In/c	2 times a day
Antibacterial drugs of different groups
Co-trimoxazole	20 mg/kg body weight (by trimetrome)	Inside	4 times a day
Amphotericin c	Start with 100,000-150,000 units, gradually increasing by 50,000 units by 1 administration 1 time in 3 days to 500,000-1,000,000	In/c	1 time in 3-4 days
Fluconazole	6-12 mg/kg body weight	Iv, Inside	1 time per day

[28], [29], [30]

Antiviral treatment of pneumonia in a child

Antiviral drugs are prescribed in the following cases:

• Convincingly justified laboratory or clinically viral etiology of pneumonia;
• Heavy virus and bacterial pneumonia.

With the established or highly-reliable flu etiology, children over one year old are prescribed by Rimantadin. In addition, starting from the first days of life, you can use the recombinant A-interferon - Viferon. Indications for its use are rhin-, crown, RSC and adenovirus infections, influenza and paragraph. Viferon is prescribed to children up to 3 years old, 150 IU 2 times a day in candles for 5 days, children over 3 years old, 500 LLC 2 times a day in candles for 5 days. There should be 2-3 such courses with an interval of 5 days.

[31], [32], [33], [34], [35]. [36]

Immunorous therapy

Recommendations for the appointment of immunocorrigating drugs in the treatment of pneumonia in children are still under study.

Indications for the appointment of immunocorrogative therapy:

• Age up to two months;
• The presence of modifying factors, with the exception of social and social;
• High risk of adverse outcome of pneumonia;
• Complicated pneumonia, especially destructive.

In these cases, along with antibiotics, replacement immunotherapy is necessarily freshly frozen plasma and immunoglobulins for intravenous administration. Immunoglobulins are prescribed as early as possible-on the 1-2th day. They are administered in ordinary therapeutic doses (500-800 mg/kg), at least 2-3 administrations per course, daily or every other day. At the same time, it is desirable to achieve an increase in the level of the patient’s blood of more than 800 mg/DL.

With destructive pneumonia, the introduction of immunoglobulins containing and ^m, i.e. Pentaglobin4.

Symptomatic treatment of pneumonia in a child

Antitratic therapy is one of the main areas of symptomatic therapy. The drugs of choice are mucolytics that liquefy bronchial secret due to changes in the structure of mucus (Ambroxol, acetylcysteine, bromhexin, carbocysteine). They are used orally and in inhalation for 7-10 days.

Antipyretic therapy

Currently, the list of antipyretic drugs used in children is limited by paracetamol and ibuprofen. Indication for their purpose is febrile fever (over 38.5 ° C). At body temperature over 40 ° C, a lytic mixture is used (aminazine 0.5-1.0 ml of a 2.5% solution of + 0.5-1.0 ml of a solution of pipolfen intramuscularly or intravenously). In severe cases, 0.2 ml per 10 kg of an analgin solution is added to the mixture.

[37], [38], [39], [40], [41]. [42], [43]

Assessment of the effectiveness of pneumonia treatment in children

The ineffectiveness of therapy and the high risk of an unfavorable prognosis of the disease should be said if within the next 24-48 hours it is noted:

• Increase in respiratory failure, reducing the ratio of RAO2/P1O2;
• A drop in systolic pressure, which indicates the development of infectious shock;
• An increase in the size of pneumonic infiltration by more than 50% compared to the source;
• Other manifestations of multiple organ failure.

In these cases, after 24-48 hours, the transition to alternative drugs and the enhancement of functional support of organs and systems is shown.

Stabilization of the condition during the first 24-48 hours from the onset of treatment and some regression of radiological changes and homeostatic disorders for the 3-5th day of therapy indicate the success of the chosen tactics.

The transition to taking antibacterial drugs inside is shown:

• With persistent normalization of body temperature;
• With a decrease in shortness of breath and cough;
• With a decrease in leukocytosis and neutrophilia in the blood.
• Usually it is possible in severe pneumonia on the 5-10th days of treatment.

X-ray examination in dynamics in the acute period of the disease is carried out only if there is a progression of symptoms of lung damage or with the appearance of signs of destruction and/or the involvement of pleura in the inflammatory process.

With a distinct positive dynamics of clinical manifestations, confirmed by dynamic radiographs, there is no need for control radiography during discharge. It is more advisable to conduct it outpatiently no earlier than 4-5 weeks from the onset of the disease. Mandatory radiological control before the discharge of the patient from the hospital is justified only in cases of complicated course of pneumonia.

In the absence of positive dynamics of the process during 3-5 (maximum 7) days of therapy, a protracted course, torpid to the therapy, it is necessary to expand the survey circle as in terms of identifying unusual pathogens (C. psittaci, P. Aerugenoza, Leptospira, C. Burneti), and in terms of identifying other diseases Light.

Read also: Treatment of pneumonia Treatment of hospital pneumonia

[44], [45], [46], [47]

Pneumonia Prevention in children

The basis of the prevention of community-acquired pneumonia is adequate treatment of the infection of the upper respiratory tract, especially in often ill children and in children with bronchial concrete syndrome. Particular attention in the treatment of acute respiratory infections should also be paid to children suffering from encephalopathy, congenital malformations, children with hypotrophy of the II-III degree. In addition, children suffering from chronic diseases of the lungs (bronchopulmonary dysplasia, bronchial asthma), diseases of the cardiovascular system, kidneys (nephritis), oncgetological diseases and patients with immunodeficiency.

List of literature

Tatochenko V.K., Sereda E.V., Fedorov A.M. et al. Antibacterial therapy of pneumonia in children: a manual for doctors. - M., 2001.

Rational pharmacotherapy of childhood diseases: Guide for practitioners: Prince. 1 / under the general. Ed. A.A. Baranova, N.N. Volodin, G.A. Samsygina. - M.: Litterra, 2007. - S. 451 - 168.

Respiratory tract infections in young children / Ed. G.A. Samsygina. - M.: Miklosh, 2006. - S. 187-250.

The technical base for the recommendations of WHO for the management of children with pneumonia: a document Who/ARI/91/20. - Geneva: Who, 1991.

Buckingham S.C. Incidence and Etiologies of Complicated Pneumonic Effusion In Children 1996-2001 // Pediatr. Infect. Dis. J. - 2003. - Vol. 22, N 6. - P. 499-504.

Juven T., Mertsola J., Waris M. et al. Etiology of Community-Cquired Pneumonia in 254 Hospitalized Children // Pediatr. Infect. Dis. J. - 2000. - Vol. 19. - P. 293-296.

Henrickson K.J. // Seminars in Pediatric Infection Diseases. - 1998. - Vol. 9, N 3 (JULY) - P. 217-233.

Guidelines for Manadegment of Adult Community - Acquired Lower Respiratory Tract Infections. European Study on Community-Cquired Pneumonia (Esocap) // Committee. EUR. Resp. J. - 1998. - Vol. 14. - P. 986-991.

Bush A., Carlsen R.-H., Zach M.S. Growing Up with Lung Disease: The Lung in Transition to Adult Life // Ersm. - 2002. - P. 189-213.

Tatochenko V.K., Samsygina G.A., Sinopalnikov A.I., Uchaykin V.F. Pneumonia in children // Pediatric pharmacology. - 2006. - T. 3, No. 3. - S. 38-46.

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